Plan Details

For this lesson, we will be going over some of the key terms that you need to understand. These terms are what are used when you send over the plan details – and when reviewing with the client, you will want to briefly touch on a few of them to help them better understand what they are getting, while also showing your expertise.

First is the plan name and network – All carriers offer different plans and networks. For example, this plan by Ambetter is the CMS Standard Silver Value – HMO. 

HMO – Is insurance that has a network of doctors to chose from within Client’s State. Any doctors outside of that would need a referral from the clients primary care doctor.

PPO – Client would have the flexibility to see providers outside of their network / State. These plans usually have a higher monthly premium.

EPO – Services are covered only if client goes to doctors in-network / In their Zip Code, except for an emergency.

Monthly premium – What the client will have to come out of pocket on a month to month basis to keep the coverage. We will touch base on the monthly premium in later videos.

Deductible – The deductible is what the client would have to come out of pocket before the insurance company kicks in and covers the rest for major events. That’s why it’s important to find someone a $0 deductible if possible. (Basic services are not affected by the deductible.

Out-of-Pocket-Max – This is the most a client would have to pay during a coverage period. Think of it as a safety net in the event of major health problems. The out of pocket max legally protects a client from having to pay any more than what’s stated.

Doctor Visit – Visits with a primary care provider. Regular checkups are typically always free.

Specialist Visit – A specialist such as a cardiologist, or dermatologist – and are for when the client needs to see someone for a specific area or condition of the body.

Wellness – Preventive care visits such as screenings, immunizations, etc.

Generic RX – Generic prescriptions are identical to the brand name in terms of effectiveness, but are substantially cheaper.

Brand RX – Brand drugs are more expensive, but sometimes there are no alternatives. For example – a diabetes medication that may not have an alternative may be 500, but on this plan it is only 15$.

X-Rays, Imaging [CT/PET/MRI], and Blood Work – All tests a doctor would run to diagnose a condition. The % is what the client is liable to pay before the insurance company covers the rest.

Urgent Care – Used when it’s a non-life threatening condition and the primary doctor is not available.

Mental Therapy – is things such as rehab and other mental or behavioral health services.

These are all the key terms we use for our quoting, but feel free to go to Healthsherpa and read through the other key terms if needed.